James Breedin cannot keep track of how often he has been admitted to Howard University Hospital in Washington, D.C., for heart problems. "It's been so many," said Breedin, a 75-year-old disabled truck driver.
One reason for his frequent returns, he says, is that he often can't afford the medications his doctor prescribes to keep his heart problems in check, "so I have to do without." And though his doctors recommend regular physical activity -- a lifestyle change that could also cut the chances he will find himself in the hospital again -- he said he fears exercising outside because of neighborhood violence.
Medicare is preparing to penalize hospitals with frequent, potentially avoidable readmissions, which by one estimate costs the government $12 billion a year. But this new policy is likely to disproportionately affect hospitals that treat the lowest-income patients, according to a Kaiser Health News analysis of data from the Centers for Medicare and Medicaid Services.
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Hospitals that served the poorest Medicare patients were nearly three times as likely as others to have substantially high readmission rates for heart failure, the analysis found. At these hospitals -- which include Howard in the District of Columbia, Johns Hopkins Bayview Medical Center in Baltimore and New York-Presbyterian Hospital and the Mount Sinai Hospital, both in New York City -- low-income people comprised a greater share of the patients than they did at 80 percent of hospitals.
Heart failure is the most common condition sending Medicare patients back into the hospital. Fluid often builds up when the heart pumps poorly. To get rid of it, doctors prescribe drugs to speed up the heart or make patients urinate more frequently. But much of the recovery depends on what happens to patients after they leave the hospital. Physicians say low-income people often can't afford the medications they are prescribed or the more healthful food they are directed to eat. They also can have difficulty understanding the sometimes complex instructions they are given about how to take care of themselves.
"These patients tend to be sicker; their problems tend to be more advanced," said James Diggs, Breedin's cardiologist at Howard. "We have patients who are readmitted almost every two months for heart failure. We almost save a bed for them."
Within 30 days of discharge, one of every four Medicare patients with heart failure is readmitted. The Affordable Care Act, which Congress passed last year, mandated that starting next October, Medicare will penalize hospitals where patients with heart attacks, heart failure or pneumonia return frequently.
By 2014, hospitals with high readmission rates stand to lose up to 3 percent of their regular Medicare reimbursements. Although Medicare hasn't finished determining exactly how the penalties will work, the Advisory Board Company, a Washington consulting firm, estimates that as many as 2,300 hospitals may lose money because of the rule, with Medicare dinging the worst performers up to $500,000.
Medicare has set aside money to help hospitals plan patients' post-discharge care better. Patrick Conway, Medicare's chief medical officer, said some of that money would be targeted to hospitals with lots of poorer people. "We especially are concerned about safety-net hospitals that take care of a high portion of patients in poverty and racial and ethnic minorities," he said. But he said the agency is committed to the readmission penalties, both because it is required to by law and because it believes the penalties will encourage hospitals to make sure patients get the follow-up care they need.